The browlift has been a part of the aesthetic surgeon’s armamentarium for rejuvenation of the upper third of the face for almost a century. Early descriptions by Passot recommended excision of ellipses of skin along the hairline to raise the brow and soften crow’s feet. Since then, numerous approaches have been developed to address the ptotic brow and smooth forehead rhytids, including coronal, trichophytic, midforehead, direct brow, endoscopic, and transblepharoplasty techniques. In modern aesthetic surgery, the coronal incision with subgaleal dissection and myotomy of the procerus, corrugator, and frontalis was initially the gold standard . However, since the first published descriptions of the endoscopic browlift in by Isse , there has been a strong trend toward approaching the upper third via minimally invasive techniques.
Indications for browlift have traditionally included ptotic aging brow with or without upper lid dermatochalasis, elimination of glabellar and frontalis rhytids, and avoidance of temporal bunching in revision facelift . Occasionally, there is a functional indication for unilateral brow lift such as with facial nerve paralysis.
Despite the fact that most coronal brow lifts are performed in the subgaleal plane many investigators espouse endoscopic brow lift in the subperiosteal plane . This could be attributed to early technique reports, which suggested a more favorable optical chamber could be achieved with a subperiosteal dissection . However, an early endoscopic report by Isse describes either subgaleal or subperiosteal dissection to 3 cm above supraorbital rims and then subperiosteal dissection around the neurovascular bundles.
Troilius compared bicoronal subgaleal browlifts with endoscopic subperiosteal browlifts and concluded that subgaleal dissections resulted in descent of the brow to preoperative position at 1-year follow-up. Conversely, he found that endoscopic subperiosteal browlift patients had an increased brow height at both 1 year (mean 7 mm) and even higher at 5-year follow-up (mean increase, 2.5 mm). Combinations of endoscopic and open techniques, such as the endoscopically assisted biplanar dissection, which begin with a trichophytic incision and subcutaneous dissection and switch to the subperiosteal plane, have also been reported . The literature on endoscopic browlift is replete with authors advocating multiple different techniques and planes of dissection, sometimes without a prevailing rationale for choosing one plane over another .
A “release” of periosteum at or above the arcus marginalis is cited frequently as the critical factor in achieving adequate and durable brow elevation . To clarify the role of periosteal release and plane of dissection, the senior author performed controlled cadaveric experiments comparing brow and forehead elevation and flap tension in three surgical techniques: (1) subperiosteal dissection without arcus release, (2) subperiosteal dissection with arcus release, and (3) subgaleal dissection. Periosteal release resulted in no significant difference in forehead elevation at rest or with 2.2 kg traction ( P > .05); furthermore, no difference was noted between subgaleal and subperiosteal dissection under the same conditions ( P > .05) . And, although not statistically significant, median flap tension was greater for subperiosteal dissection with release than for subgaleal dissection ( P > .05). Based on these data and continued success of clinical results, the subgaleal technique has been recommended by the senior author in endoscopic brow lift cases.
Browlift outcomes recently have come under scrutiny. The 2001 National Plastic Survey found that plastic surgeons nationwide thought coronal browlifts were more effective than endoscopic browlifts . Furthermore, this survey reported similar alopecia rates between coronal (4%) and endoscopic (2.9%) browlifts, despite the common perception that endoscopic approaches avoid alopecia complications. Lastly, permanent sensory loss was actually reported to be lower with a coronal approach (0.1%) compared with endoscopic brow lifts (0.57%) despite the subperiosteal “safer plane” . In another recent survey, a large urban center reported declines of 70% in the number of browlift procedures performed from 1997 to 2001, despite no change in the frequency of other cosmetic surgeries . The authors attributed this to disenchantment with the browlift procedure, as only 50% of surgeons reported being satisfied with 2-year browlift outcomes. Patients, however, reported a higher satisfaction rate of 70% .
We have been pleased with long-term outcomes of endoscopic subgaleal browlift. The senior author’s technique is described below and incorporates an endoscopic approach in the subgaleal plane and uses absorbable fixation.
Preoperative considerations
On initial consult, the patient’s brow position is examined carefully in the resting and animated position, with reference to the supraorbital rim. Brow shape and symmetry are noted, as slight asymmetries may be correctable. The ideal brow elevation can be seen with finger retraction while the patient is seated upright and looking in a hand mirror. The vectors of pull are critical—superior and slightly lateral elevation of the medial brow, middle, and lateral brow should be assessed separately and noted in the surgical plan. Any redundant upper lid skin is noted after the brows are in ideal position, and concomitant upper blepharoplasty can be recommended. A preoperative browlift photograph series is taken in standardized ideal lighting conditions.
The risks of the procedure should be elaborated to the patient, including forehead sensory nerve deficit, motor nerve deficit (possibly permanent), infection, bleeding and hematoma, skin necrosis, alopecia at the endoscope ports, asymmetrical eyebrows or eyelids, irregularities in skin contour after procerus/corrugator resection, and possible over-correction. We suggest botulinum toxin A (Botox) treatment of the central frontalis and glabella area 2 weeks before browlift to facilitate and preserve the elevation and reattachment of the subgaleal plane to the periosteum without counteraction by the depressor muscles.
Surgical technique
Patient positioning and markings
With the patient seated, brow elevation is reassessed relative to the supraorbital rim. This is an important preoperative landmark to guide where the brow should be surgically positioned, because brow position changes when the patient is lying supine in the operating room. Patients undergoing concomitant upper blepharoplasty should also have their upper lids marked at this time. A realistic estimation of excess upper lid skin to be excised should be marked while the patient is upright and with the brow held in the elevated position. Browlift typically should precede blepharoplasty so that too much upper lid skin is not excised, resulting in incomplete closure.
With the patient supine in the operating room, the supraorbital notch/foramen can be palpated, and the exit point of the nerve should be marked. The supratrochlear foramen lies approximately 1 cm nasal (or 1.7 to 2.2 cm lateral to midline) and should also be marked. During endoscopic dissection, these external landmarks are a reminder to avoid injury to the neurovascular bundle.
Four scalp incision sites are also marked. Paramedian incisions 2 cm long are marked, approximately 1.5 to 2 cm posterior to the frontal hairline in a sagittal plane. Temporal incisions of about 3 cm in length are also marked, 1.5 cm posterior to the temporal hairline in the coronal plane. Occasionally, a central incision site is also marked in patients with high or broad foreheads to give an additional endoscopic port and facilitate dissection. Hair is placed in sterile rubber band bundles to better expose the markings.
Anesthesia
Endoscopic browlifts may be performed under monitored intravenous sedation or general anesthesia depending on the comfort level of the surgeon, the patient, and the anesthesiologist. After adequate sedation, 1% lidocaine with 1:100,000 epinephrine is infiltrated around the supraorbital and supratrochlear nerves (approximately 1 mL each) and at the planned paramedian and temporal incision sites (approximately 2 mL each). Small blebs are also injected into the subgaleal plane across the forehead region (approximately 3 mL).
Subgaleal dissection
Paramedian incisions are made first using a 15 blade, parallel to the hair shafts, extending down to but not through the periosteum. The semisharp curved dissector is advanced into the subgaleal plane, similar to a coronal browlift, and the entire central pocket is dissected without endoscopic visualization until approximately 1 cm above the supraorbital rims. To safely dissect the orbital rims, the sheathed endoscope is inserted into the paramedial ports, gently tenting the forehead skin to optimize the optical cavity. The neurovascular bundles are directly in view, emerging from the supraorbital rim in the subgaleal plane, and endoscopic dissection proceeds carefully to avoid injury to the nerves and vessels ( Fig. 1 ). When adequate exposure has been achieved, a consolidation of temporalis fascia is visible at the lateral aspects of the cavity. At the level of the orbital rim, the galeal layer is divided completely using the semisharp curved elevator to release the forehead flap. No subperiosteal incisions or dissection are performed. A continuous release is achieved in the subgaleal plane across both superior orbital rims and nasal radix-glabellar region. The forehead flap is then freely mobile and can be elevated and positioned optimally.
Temporal dissection
The temporal incisions are then made down to the superficial layer of the deep temporal fascia. This plane can be identified as the layer that is directly adherent to the temporalis muscle and resists movement; a small cut through this dense white fascia reveals the temporalis muscle immediately below. Any bleeding at the incision sites is controlled with conservative bipolar electrocautery specifically directed at the vessels to avoid damaging the hair follicles and creating postoperative alopecia. Endoscopic visualization is not necessary for temporal elevation as long as the dissector is advanced directly along the deep temporal fascia and glides without resistance. Once the cavity is defined to the temporal line, the temporal pocket is connected to the central pocket by taking down the consolidation of temporalis fascia. This is done under direct visualization to maintain the correct plane and avoid damage to the frontal nerve ( Fig. 2 ). The temporal and forehead flaps should not be tented with too much tension, or neuropraxia may result.
Musculature
The subgaleal plane allows direct access to the corrugator, procerus, and depressor supercilii muscles for conservative modification. The neurovascular bundles are also easily visualized in this plane, approximately 1 cm superior to the orbital rim. The supratrochlear neurovascular bundle passes through its foramen/notch and exits the orbit by piercing the orbital septum. It passes superficial to the corrugator supercilii and deep to the orbicularis oculi and at the level of the brow, then pierces the orbicularis and frontalis muscles, and continues superiorly in the subcutaneous plane (see Fig. 1 ). However, in up to 10% of patients, these nerves may arise from a foramen 1 to 2 cm superior to the supraorbital rim and can thus be injured if endoscopic visualization is not used . The corrugator is identified running horizontally, deep to the neurovascular bundles both nasally and temporally. The procerus is found running vertically, directly over the nasion. A reverse curved sharp elevator is used to incise the muscles perpendicular to their course, both medial and lateral to the neurovascular bundles. Overly aggressive resection of brow musculature can create visible irregularities in the skin when the forehead flap is redraped, so conservative resection is recommended. Hemostasis is obtained with bipolar cautery if needed, avoiding the neurovascular bundles. If horizontal forehead rhytids need to be addressed, the frontalis can be weakened in a similar fashion with conservative horizontal cuts. Bimanual palpation should be used to discern the depth of the cuts to avoid cutting through to skin. However, we are increasingly using botulinum toxin A injections postoperatively on a periodic schedule to control muscle contraction rather than relying on surgical manipulation.
Absorbable fixation devices
There are several acceptable fixation techniques available to the surgeon. In previous years, the senior author placed one or two 3-0 polydioaxanone (PDS) fixation sutures through the galea superior to the brow, suspended from a bone bridge or absorbable screw at the scalp incision . We now use the Endotine Forehead (Coapt Systems, Inc, Palo Alto, CA) bioabsorbable device for fixation. The device consists of an L-lactide/glycolide (82:18) copolymer with a triangular base, calvarial post, and projecting tines to support the flap. The device is positioned such that the platform sits approximately 1 cm posterior to the frontal hairline and anterolateral to the paramedian incision with the brow in optimal elevated position ( Figs. 3 and 4 ). The site of the post is noted, and the periosteum is incised and elevated in this area to seat the device directly against the calvarium. Minimal subgaleal dissection posterior to the paramedian incisions across the coronal suture is performed to avoid scalp bunching on closure. After drilling with a guarded drill bit, the Endotine post then is seated into the hole, and the device snaps into place firmly against the calvarium. The contralateral device is then placed in a similar manner, and the brow is elevated and suspended in the new position. Firm digital pressure is required to engage and penetrate the galeal layer ( Fig. 5 ). At this point, the brows should be scrutinized for symmetry and ideal elevation in the medial, middle, and lateral portions. Unlike conventional suture technique, if the brows are not perfectly symmetric, the flap can be disengaged easily and resuspended until the results are satisfactory. This is especially helpful in patients who need asymmetric elevation in either the isolated medial brows or in a portion of one brow. The lateral brow and temporal flap is further supported with a 3-0 PDS suture, placed in the flap anteriorly and secured to the deep temporal fascia posteriorly ( Fig. 6 ).
Wound closure and dressings
The four incisions are closed with deep buried galeal sutures of 4-0 PDS. Scalp skin then is closed with surgical staples, maintaining a tension-free environment to avoid alopecia. During closure, care is taken not to raise the forehead flap and accidentally disengage it from the Endotine prongs. If the patient is to undergo upper lid blepharoplasty or other rejuvenation procedures, these are performed then. At the conclusion of the procedure, the brow position is again rechecked and readjusted as necessary. Fluffs are placed at the brow and temporal area, covered by gauze wrap and an elastic outer layer to support the newly elevated brow.
Postoperative follow-up
The dressing is removed on the first postoperative day, and the forehead flap is examined. A new dressing is placed in a similar fashion and is removed on the following day. On the third day, an elastic face-band dressing is placed across the forehead and is worn until postoperative day 7. Scalp staples are removed 7 days after surgery, and the elastic band is worn during the nights only for an additional 2 weeks. A photographic brow series is taken 2 weeks after surgery and again during periodic follow-up visits at 1 month, 3 months, 6 months, and then yearly.
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